“The new warning will be added to the prescribing information and the patient medication guides for all single and combination agents in the glucose-lowering SGLT2 inhibitor class of drugs approved to treat type 2 diabetes. Those drugs include the following:

Necrotizing fasciitis of the perineum, also called Fournier’s gangrene, is an extremely rare but life-threatening bacterial infection of the tissues underlying the skin surrounding the perineal muscles, nerves, fat, and blood vessels. It is estimated to occur in about 1.6 of 100,000 males annually in the United States, most often among those aged 50 to 79 years (3.3/100,000).

However, from March 2013 to May 2018, the FDA received reports of 12 cases of Fournier’s gangrene among patients taking SGLT2 inhibitors, of whom five were women and seven were men. The condition has rarely been reported among women. The patients ranged in age from 38 to 78 years.”

Read on at Medscape to find out about treatment options and what patients and healthcare professionals should do.

A high school Valedictorian in Texas announced that she was an undocumented immigrant this week, sparking a debate about who should and should not be enjoying the benefits of residency in the US. Larissa Martinez stated the following:

Lovely, brilliant Valedictorian

“By sharing my story, I hope to convince all of you that if I was able to break every stereotype based on what I’m classified as — Mexican, female, undocumented, first generation, low-income — then so can you.”

My maternal grandparents are from Italy. My mother is a first-generation American. I was the first person in my family to go to college, which happened later in my life because my parents didn’t really see the benefit. After all, my father never graduated high school, and no one in either of their families had been to college and they turned out just fine.

Naturally, in our changing economic climate that was a mistake. However, back to the undocumented part… When my grandparents came here it was much easier to become a legal resident of the US. My grandfather was so unbelievably proud to become an American Citizen, after the long and grueling process of naturalization. He only spoke Italian when he arrived, and worked at low-paying jobs doing manual labor. He learned English. He studied, he sweated, and he passed the test after 12 years.

Larissa says that she and her mother have been trying to become a citizen for seven years, and that the US Immigration system is broken.

I am going to make comparisons here. Preparing for the tomatoes.

While the US Immigration system is probably broken, the Mexican Immigration system is equally as convoluted and full of red tape. I cannot just walk into Mexico with my children and set up housekeeping, as Larissa’s mother did. News stories I read about her family stated that they ‘fled’ to the US; from an abusive, alcoholic father, apparently. It seems to me that it was probably not necessary to illegally enter the US for that reason. I will assume that Larissa’s mother wanted an American life for her children.

In 2011, the Mexican government enacted a ‘softer’ law about undocumented immigrants to Mexico. Up until then, this was the law:

Under the Mexican law, illegal immigration is a felony, punishable by up to two years in prison.

Immigrants who are deported and attempt to re-enter can be imprisoned for 10 years.

Visa violators can be sentenced to six-year terms.

Mexicans who help illegal immigrants are considered criminals.

The law also says Mexico can deport foreigners who are deemed detrimental to “economic or national interests,” violate Mexican law, are not “physically or mentally healthy” or lack the “necessary funds for their sustenance” and for their dependents.

Sick and poor undocumented people are not supported by the Mexican government.

So, when Larissa’s family arrived in the US, the law in Mexico was pretty harsh. Had I done the same thing with my children, I would have been imprisoned for two years and charged with a felony, then deported. The law has since been changed to an administrative and financial penalty, and it is possible to obtain Mexican residency unless you are sick or poor. Larissa’s family was poor.

Having said all that, am I in favor of deporting all undocumented immigrants? No, of course not. I am in favor of naturalizing them; they already live here and contribute to the economy. As a matter of fact, they have historically contributed to Social Security and never collect the benefits. Of course, there are people who work “Off the books”, but the large majority actually contribute to all payroll taxes via a false Social Security number. And this is not the fault of their children, who know no other life.

However, if they commit crimes against other people, I am in favor of instantly deporting them. Not in a year, not after a prison term that we pay for. That very moment. Mexico can keep her problem children. They have high standards for Americans emigrating to Mexico.

Let’s get to the healthcare part! 🙂

The Affordable Care Act specifically prohibits undocumented immigrants from purchasing health insurance through the marketplace. Undocumented immigrants can sometimes get coverage through an employer. They can purchase private health insurance, which is expensive. If they are a college student, they can purchase a student plan through a university. These are usually cheap.

Also, a 2012 federal law provides temporary work authorization and relief from deportation to undocumented children and young adults who arrived in the U.S. before turning 16. It’s part of the Deferred Action for Childhood Arrivals law, known as DACA. Undocumented immigrants who qualify are eligible. Since we really cannot blame kids for the actions of their parents, I think it is a good concept. In California, undocumented immigrants may be allowed coverage under Medi-Cal if they have DACA status.

I see no problem with undocumented immigrants buying health insurance through the marketplace. More people = lower prices according to our government. Also, these folks currently seek primary care in Emergency Departments all over the US because they have no insurance. 11 million undocumented people can clog up a lot of ED’s. Let’s make them pay for insurance like everyone else, and stop using the ED as a PCP’s office.

While I do not have the answer to the problems we have with undocumented immigrants, I would say that Larissa probably made an error when she did this. Many people will see it in a negative light. She is still in the country illegally. I hope Yale knows her immigration status, and that she is prepared to get a student visa. She is a smart kid, so she probably thought of this.

However, great job on those grades, girl! I hope you are a great neurosurgeon.

Imagine 13 people in your town dying from medical errors this year. Which 13 people will they be? Your kid’s little league coach? Your old piano teacher? The lady who has been giving you fresh tomatoes from her garden for the last decade? A person you have a nodding acquaintance with? A stranger?

Does it matter?

The public is aware of deaths from breast cancer, accidents, strokes, Alzheimer’s disease, diabetes, influenza, and suicide. There are huge campaigns for many of these diseases and disorders. Pink for the Cure, Strokes, and Suicide Prevention have billboards up in cities all over the nation. And medical errors are a silent, pervasive killer. We do not notify the public about it, we do not educate them about it, and blatant medical error deaths are very frequently attributed to other causes.

How do I personally know this? I am one nurse out of nearly five million and I can cite TWO deaths which were blamed on other things. One of the two was a nurse medication error, and she was insanely busy at the time. She gave short-acting insulin instead of long acting insulin. Nearly 100 units; and the patient died 45 minutes later with a blood sugar of 13. One was a failure-to-rescue death because the nurse was too new to be on her own and didn’t know what she was looking at. The charge nurse was busy, and she had no mentor. I personally watched these two patients die.

And what about the near misses? I have seen someone accidently bolus a patient with an insulin drip because she placed the tubing in the wrong IV pump channel when moving the patient from a chair to a bed. (that one lived) I have seen patients given medications they were allergic to. I have seen incidents of the the wrong ACLS protocol drugs being given (or given in the wrong dosage to a pediatric patient). I am ONE NURSE, and I graduated in 2007.

This cannot be.

As usual, we can attribute these incidents to staffing problems. No mentor, insanely busy and understaffed, no experienced nurse to back up a new nurse. How many bodies will we have to step over to get to a point where we are adequately staffed? Will it be the body of your kid? Your grandfather? Your UPS guy? Your neighbor?

Does it matter?

We educate the public. We are nurses. Start educating the public by walking for patient safety to #SavePat. Details available soon. Rally in DC on May 4, 2017 to convince your legislators that this is one leading cause of death we can actually do something about!

Call AARP and encourage them to educate their members. Call your senator. Ask them if they are going to #SavePat.

[box]Let’s say you are on the SMYS Mission to Haiti with NO Cardiologist anywhere for a few hundred miles. [/box]

Your patient presents with dizziness and shortness of breath upon exertion, transient chest pain, and fatigue. There is a 12 lead EKG available which shows normal sinus rhythm, and no ST elevation, but there is T-wave inversion in the inferior leads. The patient complains of dizziness during the EKG, with no exertion and no dysrhythmia. He has no pain at the moment.

You hear SOMETHING when you listen to the heart, but you are not sure what it is because you have never heard it before. You have nothing to compare it to, and neither does anyone else at this remote Haitian outpost. It is not a normal heart sound, and that is all you can be sure about.

What do you do?

There is no Cardiologist. Transporting every patient with these symptoms is just not an option. These people are poor, and emergency care is a precious resource. For that matter, is this sound an emergency? Is the patient having a bit of atrial fibrillation, but transient and with an overall low burden? Or is there something structurally wrong with the heart? Are those sounds you are hearing the classic auscultatory finding of Mitral Valve Prolapse; a mid-to-late systolic click followed by a late systolic murmur? Does this person need a Cardiac Cath, an ECHO, an aspirin regimen, or a wait-and-see?

You don’t know. How do you find out? Turn to the Eko Core!

So, what is this thing? The Eko Core Digital Stethoscope is the first & onlyFDA-approved digital stethoscope on the market to let clinicians amplify heart & lung sounds 40X, wirelessly sync to the HIPAA-compliant Eko Mobile App, visualize, record, save sounds, and forward them on for a second opinion.

Why is it important? The Eko Core Digital Stethoscope is bringing the stethoscope into the 21st century. Now clinicians can hear heart & lungs sounds more clearly, and get support from their team across the hospital or across the globe. The sounds can also be integrated into the EHR and monitored over time for better consistency of care. The Eko Core and Mobile App is being used in cardiology, newborn screenings, pediatric cardiology, teaching, telemedicine, low-resource care, and primary care by clinicians at hundreds of institutions across the country including Harvard, Mayo Clinic, UCSF, and more.

This is what a 21st century stethoscope looks like!

There are two versions of the Eko Core:

1. “Eko Core Attachment” ($199) attaches onto the regular stethoscope you already have! It attaches to almost all known stethoscope brands such as Littmann, Welch Allyn, ADC, and Ultrascope. You can digitize your own stethoscope!

2. “Eko Core Bundle” ($299) includes the Eko Core Attachment pre-attached to a cardiology-grade stethoscope. Just take it out of the box, and it’s ready to go.

Impact on global health: The Eko Core Digital Stethoscope can be used to improve access to specialty care to billions of patients in low-resource countries around the world. Take Haiti, the poorest country in the western hemisphere with the highest rate of maternal & infant mortality. Eko is used by clinicians in rural clinics there as a relatively inexpensive tool for cardiopulmonary screenings and to secure specialist second-opinions. It can even be live-streamed. Recently, a Nurse Practitioner in Haiti used an Eko Stethoscope to wirelessly send heart sounds to a Cardiologist for a consult…who happened to be on a cruise at the time. Check out the article on it here here. How awesome is that?

And this company is so cool they are partnering with Show Me Your Stethoscope by providing Eko stethoscopes for our Mission Trips!!

And….Visit www.ekodevices.com for more info and use discount code SMYS2016 at checkout! Members get a $15 discount, AND Eko will donate $15 for every order to the SMYS Foundation.

Apparently people love this thing…. Check out the awards and recognition.

A surgical department called for a patient to be transported…..and a patient was transported to the department.

The wrong patient.

So, the nurse gave the correct patient name to the secretary, who gave the wrong name to the nurse. That nurse gave the name of her patient (who was not having a procedure) to transport. Transport brought the patient.

And thankfully, the nurse in the surgical area checked the ID band. Because the patient said, “Well, I might need (this specific surgery that is done in this department)”.

So we all know what a Never Event is, but I am going to post information anyway. These are the ‘never’ surgical events, from the National Quality Forum:

The person who is actually performing the procedure must Mark the site.

ID Must be checked by EVERYONE involved in a handoff of a patient.

We include the procedure in the time-out, and the surgeon, and all people involved with the surgery have verified that the patient is having this procedure and consents to it.

We Count sponges, sharps, etc at the beginning and ending of every case.

We do it right, and pay attention.

Simple enough, right?

What happens when you are busy? Naturally, you do the same things, no matter what.

Unless…

The Secretary had four family members at the desk yelling at him, misheard the nurse on the phone, and gave the nurse on the floor a sound-alike name.

The nurse on the floor has seven patients on telemetry, and is juggling admissions, discharges, and procedures. He has had no time to talk to any medical staff, and assumed the procedure was an add on, since the patient had a similar problem.

The transporter takes the patient, who has no idea what is going on. The patient trusts the hospital, and the nurse, and doesn’t ask any questions.

The nurse in the surgical area immediately verifies the ID band with the OR schedule. It does not match. She figures out what happened, and sends the patient back

The procedure is done on the correct patient, after the mistake is fixed.

This is why we do the things we do. That patient could very well have had the wrong procedure done. The surgeon had only briefly met the patient, and we hope that he would have remembered that this was a different face, and checked the ID band himself. We hope the patient would have realized that no one talked to him about the invasive procedure he was about to have done. We hope that the staff actually did the time out they charted.

We are members of a profession that owns the trust of the public. We do these things with every patient, every single time because we know that never events are possible. Perhaps our hospitals and other healthcare facilities can help us prevent never events by staffing us appropriately. Because nobody is perfect.